Provider Demographics
NPI:1447369228
Name:LEBLANG, JEFFREY HERMAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HERMAN
Last Name:LEBLANG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 WHITEHALL DR
Mailing Address - Street 2:PLANTATION TRACE
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-4549
Mailing Address - Country:US
Mailing Address - Phone:318-747-2124
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001565103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAVAD000Medicare UPIN